What are the medical management options for Polycystic Ovary Syndrome (PCOS)?

Medical Management for PCOS

The first-line treatment for Polycystic Ovary Syndrome (PCOS) should be a multicomponent lifestyle intervention including diet, exercise, and behavioral strategies, particularly for patients with excess weight. 1, 2

Lifestyle Interventions

Dietary Recommendations

• Implement a balanced dietary approach with an energy deficit of 30% or 500-750 kcal/day (1,200-1,500 kcal/day) to achieve weight loss, considering individual energy requirements 2
• No specific diet type has proven superior for women with PCOS; focus should be on individual preferences while maintaining nutritional balance 2
• Low glycemic index foods, high-fiber diets, and anti-inflammatory diets can improve insulin sensitivity and hormonal balance 3

Physical Activity Recommendations

• Adults should engage in a minimum of 150 minutes/week of moderate-intensity physical activity or 75 minutes/week of vigorous intensity for health maintenance 2
• For weight loss and greater health benefits, increase to 250 minutes/week of moderate-intensity activities or 150 minutes/week of vigorous intensity 2
• Both aerobic and resistance exercise improve insulin sensitivity and metabolic outcomes in PCOS 4, 3
• Examples of moderate-intensity activities include brisk walking, cycling (8-15 km/h), low-impact aerobics, and yoga 4
• Examples of vigorous-intensity activities include jogging/running, high-impact aerobics, and competitive sports 4

Behavioral Strategies

• Implement SMART (specific, measurable, achievable, realistic, timely) goal setting and self-monitoring 2
• Include stimulus control, problem-solving, assertiveness training, and relapse prevention techniques 2
• Set achievable weight loss goals of 5-10%, which can yield significant clinical improvements within 6 months 2

Pharmacological Management

Insulin-Sensitizing Agents

• Metformin can help improve insulin resistance, which is present in approximately 70% of PCOS cases 5, 6
• Particularly beneficial for patients with metabolic dysfunction and increased risk of type 2 diabetes mellitus 5

Ovulation Induction

• Clomiphene citrate is indicated for treatment of ovulatory dysfunction in women with PCOS desiring pregnancy 7
• Should be started on or about the 5th day of the cycle once ovulation has been established 7
• Not recommended for long-term cyclic therapy beyond a total of about six cycles 7
• Caution: Monitor for ovarian hyperstimulation syndrome (OHSS), which can progress rapidly and become serious 7

Weight Management Medications

• Orlistat may help achieve weight loss and improve lipid and glucose metabolism in PCOS patients 5

Monitoring and Follow-up

• Regular monitoring of weight and waist circumference is essential during weight loss and maintenance 2
• Body mass index (BMI) calculation and waist circumference measurement are essential for assessing central obesity 1
• For ethnic groups with high cardiometabolic risk, ethnic-specific BMI and waist circumference categories should be considered 1

Common Pitfalls and Caveats

• Women with PCOS experience greater weight gain over time compared to unaffected women, making early intervention crucial 2
• Central obesity increases over time in PCOS, with progressive increase in waist-to-hip ratio between ages 20-45 years 2
• Avoid weight-related stigma during health professional interactions, as this can negatively impact treatment engagement 2
• For patients taking clomiphene citrate, monitor for visual symptoms (blurring, scotomata) which require immediate discontinuation and ophthalmological evaluation 7
• Patients with polycystic ovary syndrome may be unusually sensitive to gonadotropin and have exaggerated responses to usual doses of clomiphene citrate 7

Long-term Considerations

• PCOS requires long-term management to reduce risks of metabolic-related diseases including type 2 diabetes and cardiovascular disease 5, 8
• Untreated PCOS can lead to adverse pregnancy outcomes and increased risk of endometrial cancer 5
• Psychological factors such as anxiety, depression, and body image concerns should be addressed as part of comprehensive management 1